Appendix J - Data Collection Form
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1. LA code
2.
3. Examiner __________________________
5. School postcode |__|__|__|__|
4. School name _________________________________
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7. Child identity number
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9.
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Home postcode
10. Sample group code
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11. Parental consent status
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12. Examination status
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13. Plaque measurement
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Right
UPPER
E
D
C
B
A
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PCT code
6. Date of examination
8. Date of birth
0 - Main sample
3 - Additional sample C
1 - Additional sample A
4 - Additional sample D
0 - Examined
3 - Absent
1- Repeat exam
4 - Child refused
A
Left
B
C
D
E
Tooth Codes
Extracted caries.......................
Unerupted or missing other.....
Sound............. Blank, ‘-’ , Or
Hard, arrested caries...............
Decayed....................................
Decay + pulpal involvement.....
Roots only remaining………….
Filled and decayed....................
Filled.........................................
Filled, needs replacement........
Obvious sealant rest'n..............
Sealed surface .......................
Crown ....................................
Trauma.....................................
L
LOWER
B
A
A
Left
B
C
D
E
D
O
M
B
L
14. Abscess / Sepsis present
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0 - Absent
6
8
Surface Codes
B
C
2 - Training
5 - No parental consent provided
0 - Teeth appear clean
1- Little plaque visible
2 - Substantial amount of plaque visible 9 – no assessment possible
M
D
2 - Additional sample B
5 - Additional sample E
0 - Form not returned
1 - Consent refused
2 - Positive consent given as part of school block consent process
3 - Positive consent given for this survey only
O
E
| 1 | 5 |__|__|__|__|__|__|
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D
Right
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1 - Present
Optional measures
15. Ethnicity
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16. Spare variable
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0-
1-
2-
3-
17. Spare variable
|__|
0-
1-
2-
3-
18. Spare variable
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0-
1-
2-
3-
See 10.10.1
0
1
2
3
3
4
5
R
N
$
C
T